Recent epidemiologic studies suggest that women with adverse pregnancy outcomes (APOs), such as preeclampsia, are at increased risk for subsequent cardiovascular diseases. However, prospective data to elucidate the precise relationship between adverse pregnancy outcomes and subsequent cardiovascular disease are lacking. To address this critical knowledge gap, the NHLBI issued a RFA to study pregnancy as a window to future maternal health. In this proposal, a multidisciplinary team with diverse talents and expertise will define the relationship between APOs and markers of cardiovascular disease risk (CVDR) at two years after delivery. This multicenter group will utilize an ethnically, raciall, socioeconomically and geographically diverse cohort of 10,000 nulliparous women enrolled in the NICHD-funded Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b). The proposed studies are highly leveraged, utilizing the extensive and unique database and tissue bank developed in the parent study in which nulliparous women are evaluated over the course of pregnancy to study the mechanisms for and prediction of APOs. Women enrolled in the nuMoM2b cohort are extremely well phenotyped through prospective data collection, clinical evaluations, and ultrasound assessments, as well as through the use of standardized definitions. Demographic, psychosocial, dietary, physiologic, and outcome information is collected through maternal interviews, self-administered questionnaires, clinical measurements, ultrasounds, and medical record abstraction by trained personnel. Samples of maternal blood, urine, and cervico-vaginal fluid over pregnancy and cord blood and placenta at delivery are collected and banked. All women complete two sleep questionnaires and over 3,600 are recruited to perform objective overnight sleep studies at two times during pregnancy. Women participating in the nuMoM2b parent study will be assessed for evidence of CVDR, including sleep disordered breathing (SDB), at two to three years postpartum. APOs in subsequent pregnancies also will be assessed. These studies will characterize the relationship between APOs and CVDR, identify first pregnancy profiles that portend subsequent CVDR, determine associations between SDB during the first pregnancy and subsequent CVDR, and identify modifiable factors that mediate the associations between CVDR and APOs in the first and subsequent pregnancy. This will allow for the development of strategies to modify these CVDR factors and to improve the health of women suffering APOs. Relevance: NICHD is currently conducting a large study that looks for tests to identify the risk of developing pregnancy problems in women who are pregnant for the first time. In this new study, the same women will be tested again at approximately 2 years after they give birth to see if there are early signs of heart disease in those who had problem pregnancies. Information from this follow-up study will be used to improve the health of women using their experiences during pregnancy.